Co-morbidities and diet

Monday 10th September 2012

Spring 2011

Macmillan Dietitian George Anastopoulos discusses dietary options for people in palliative care with co-morbidities.

People in palliative care with co-morbidities often receive differing nutritional advice from healthcare professionals. This can be a challenging situation to be in, as well as confusing or upsetting for the patients.

Diabetes

One of the most common medical problems for people in palliative care is diabetes. In these situations, the goal shouldn’t be tight glycaemic control but symptom control instead. We don’t want to put further restrictions on an already undernourished person.

Advising on a low sugar diet for diabetes is a reasonable option when diabetes isn’t well-controlled, eg when the blood sugars are constantly in double figures despite oral hypoglycaemic agents and/or insulin treatment.

Diabetes can have serious complications, so it’s important to liaise with the diabetes team to find out how far the disease has progressed. As a rule of thumb, 10g of carbohydrate raises blood glucose by 2–3mmol. Therefore for an undernourished patient with blood sugars of less than 10mmol, it’s probably okay to have ‘that trifle’.

Remember, these patients are likely to manage small amounts anyway, so a small pot of a dessert containing 20g or even 30g of carbohydrate is fine.

If the blood sugars are consistently high, eg greater than 15mmol, then it may be wiser to suggest a low sugar alternative, with extra calories from fat and protein. In cases where appetite is very poor and the patient only expresses a desire for sweet foods, then nourishment should become a priority and preferred food choices may be offered, irrespective of the sugar content.

Sometimes blood glucose rises due to other, non-dietary reasons. Blood glucose monitoring may be required and/or a review of the patient’s diabetes medication may be needed. If the patient is on a nutritional supplement, a fibre alternative may need to be considered.

Hyperlipidaemia and cardiovascular disease

People with a history of these illnesses may have been following a healthy eating regimen for years and it can be challenging to tell them that this may no longer be appropriate. Likewise, for people who follow a low-fat diet due to history of high blood lipids, it’s a good idea to check the result of their latest blood tests.

If you’re unsure, liaise with their GP or the hospital doctor as appropriate. Quite often (especially when approaching the terminal phase) cholesterol lowering medication is withdrawn from patients’ prescriptions because the focus has shifted.

Neutropaenia

Check if the patient is still immunosuppressed and/or having further chemotherapy. If they are, then a modified diet, which is low in bacterial/fungal counts, can reduce the risk of infections.

Generally, the level of restriction recommended is dependent on the grade of neutropenia. If the patient is no longer immunosuppressed and/or having further chemotherapy, then all neutropenic diet restrictions can be lifted.

Key points

- Emphasis should be on quality of life, so eating for pleasure can become the main priority.

- Patients get information from many sources.

- Check what the patient has been told before and reassure them that previous advice was correct at the time.

- Check with the patient’s GP or care team about the likely prognosis and act accordingly, taking into account the patient’s wishes.

- Nutritional support can change with disease progression.

Related information

For more on this topic, see the new e-learning package on Learn Zone|.

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Macmillan Cancer Support, registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). A company limited by guarantee, registered in England and Wales company number 2400969. Isle of Man company number 4694F. Registered office: 89 Albert Embankment, London SE1 7UQ.